Basics of ECG

By- Pallavi Chicholikar

 What is an EKG?
•The electrocardiogram (EKG) is a
representation of the electrical events of the
cardiac cycle.
•Each event has a distinctive waveform
•the study of waveform can lead to greater
insight into a patient’s cardiac pathophysiology.
 With EKGs we can identify

Arrhythmias
Myocardial ischemia and infarction
Pericarditis
Chamber hypertrophy
Electrolyte disturbances (i.e. hyperkalemia,
hypokalemia)
Drug toxicity (i.e. digoxin and drugs which
prolong the QT interval)
 Depolarization

 Contraction of any muscle is associated with

electrical changes called depolarization

 These changes can be detected by electrodes

attached to the surface of the body
 Standard calibration
 25 mm/s
 0.1 mV/mm

 Electrical impulse
that travels towards
the electrode
produces an upright
(“positive”)
deflection
Impulse Conduction & the ECG

Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers
The “PQRST”

 P wave - Atrial
depolarization

• QRS - Ventricular
depolarization
• T wave - Ventricular
repolarization
The PR Interval

Atrial depolarization
+
delay in AV junction
(AV node/Bundle of His)

(delay allows time for

the atria to contract
before the ventricles
contract)
NORMAL ECG
The ECG Paper

 Horizontally
 One small box - 0.04 s
 One large box - 0.20 s
 Vertically
 One large box - 0.5 mV
 EKG Leads
The standard EKG has 12 leads:

3 Standard Limb Leads

3 Augmented Limb Leads
6 Precordial Leads
Standard Limb Leads
Standard Limb Leads
Augmented Limb Leads
All Limb Leads
Precordial Leads
Precordial Leads
Arrangement of Leads on the EKG
Anatomic Groups
(Summary)
 ECG RULES
 Professor Chamberlains 10 rules of normal:-
 RULE 1

PR interval should be 120 to 200 milliseconds

or 3 to 5 little squares
 RULE 2

The width of the QRS complex should not exceed

110 ms, less than 3 little squares
 RULE 3

The QRS complex should be dominantly upright in leads I

and II
 RULE 4

QRS and T waves tend to have the same

general direction in the limb leads
 RULE
5

All waves are negative in lead aVR

 RULE 6

The R wave must grow from V1 to at least V4

The S wave must grow from V1 to at least V3
and disappear in V6
 RULE 7

The ST segment should start isoelectric

except in V1 and V2 where it may be elevated
 RULE 8

The P waves should be upright in I, II, and V2 to V6

 RULE 9

There should be no Q wave or only a small q less

than 0.04 seconds in width in I, II, V2 to V6
 RULE 10

The T wave must be upright in I, II, V2 to V6

P wave
 Always positive in lead I and II
 Always negative in lead aVR
 < 3 small squares in duration
 < 2.5 small squares in amplitude
 Commonly biphasic in lead V1
 Best seen in leads II
Right Atrial Enlargement

 Tall (> 2.5 mm), pointed P waves (P Pulmonale)

Left Atrial Enlargement

 Notched/bifid (‘M’ shaped) P wave (P

‘mitrale’) in limb leads
P
Pulmonale

P Mitrale
Short PR Interval

 WPW (Wolff-
Parkinson-White)
Syndrome
 Accessory pathway
(Bundle of Kent)
allows early
activation of the
ventricle (delta wave
and short PR
interval)
Long PR Interval
 First degree Heart Block
QRS Complexes

 Non­pathological Q waves may present in I, III, aVL,

V5, and V6

 R wave in lead V6 is smaller than V5

 Depth of the S wave, should not exceed 30 mm

 Pathological Q wave > 2mm deep and > 1mm wide

or > 25% amplitude of the subsequent R wave
QRS in LVH & RVH
Conditions with Tall R in
V1
Right Atrial and Ventricular
Hypertrophy
Left Ventricular
Hypertrophy
 Sokolow & Lyon Criteria
 S in V1+ R in V5 or V6 > 35 mm
 An R wave of 11 to 13 mm (1.1 to 1.3 mV) or
more in lead aVL is another sign of LVH
ST Segment

 ST Segment is flat (isoelectric)

 Elevation or depression of ST segment by 1
mm or more
 “J” (Junction) point is the point between
QRS and ST segment
Variable Shapes Of ST Segment
Elevations in AMI

Goldberger AL. Goldberger: Clinical Electrocardiography: A Simplified Approach.

7th ed: Mosby Elsevier; 2006.
T wave
 Normal T wave is asymmetrical, first half having a
gradual slope than the second

 Should be at least 1/8 but less than 2/3 of the

amplitude of the R

 T wave amplitude rarely exceeds 10 mm

 Abnormal T waves are symmetrical, tall, peaked,

biphasic or inverted.

 T wave follows the direction of the QRS deflection.

T wave
Determining the Heart Rate

Rule of 300/1500
10 Second Rule
 Rule of 300

Count the number of “big boxes” between two

QRS complexes, and divide this into 300.
(smaller boxes with 1500)
for regular rhythms.
What is the heart rate?

(300 / 6) = 50 bpm
 10 Second Rule

EKGs record 10 seconds of rhythm per page,

Count the number of beats present on the EKG
Multiply by 6
For irregular rhythms.
What is the heart rate?

33 x 6 = 198 bpm
Calculation of Heart Rate
Sinus Bradycardia
 SA Block
 Sinus impulses is blocked within the SA junction
 Between SA node and surrounding myocardium
 Abscent of complete Cardiac cycle
 Occures irregularly and unpredictably
 Present :Young athletes, Digitalis, Hypokalemia, Sick
Sinus Syndrome
AV Block
 First Degree AV Block
 Second Degree AV Block
 Third Degree AV Block
First Degree AV Block
 Delay in the conduction through the conducting system
 Prolong P-R interval
 All P waves are followed by QRS
 Associated with : AC Rheumati Carditis, Digitalis, Beta
Blocker, excessive vagal tone, ischemia, intrinsic disease
in the AV junction or bundle branch system.
Second Degree AV Block
 Intermittent failure of AV conduction
 Impulse blocked by AV node
 Types:
 Mobitz type 1 (Wenckebach Phenomenon)
 Mobitz type 2
 Mobitz type 1 (Wenckebach Phenomenon)

The 3 rules of "classic AV Wenckebach"

1. Decreasing RR intervals until pause;
2. Pause is less than preceding 2 RR intervals
3. RR interval after the pause is greater than RR prior to
pause.
Mobitz type 1 (Wenckebach
Phenomenon)
 •Mobitz type 2

•Usually a sign of bilateral bundle branch disease.

•One of the branches should be completely blocked;
•most likely blocked in the right bundle
•P waves may blocked somewhere in the AV junction, the
His bundle.
 Third Degree Heart Block

•CHB evidenced by the AV dissociation

•A junctional escape rhythm at 45 bpm.
•The PP intervals vary because of ventriculophasic sinus arrhythmia;
 Third Degree Heart Block

3rd degree AV block with a left ventricular escape rhythm,

'B' the right ventricular pacemaker rhythm is shown.
Putting it all Together

Do you think this person is having a

myocardial infarction. If so, where?
Interpretation

Yes, this person is having an acute anterior

wall myocardial infarction.
Putting it all Together

Now, where do you think this person is

having a myocardial infarction?
Inferior Wall MI

This is an inferior MI. Note the ST elevation in

leads II, III and aVF.
Putting it all Together

How about now?

Anterolateral MI

This person’s MI involves both the anterior wall

(V2-V4) and the lateral wall (V5-V6, I, and aVL)!
Rhythm #6

• Rate? 70 bpm
• Regularity? regular
• P waves? flutter waves
• PR interval? none
• QRS duration? 0.06 s
Interpretation? Atrial Flutter
Rhythm #7

• Rate? 74 148 bpm

• Regularity? Regular  regular
• P waves? Normal  none
• PR interval? 0.16 s  none
• QRS duration? 0.08 s
Interpretation? Paroxysmal Supraventricular
Tachycardia (PSVT)
Ventricular Arrhythmias

 Ventricular Tachycardia

 Ventricular Fibrillation
Rhythm #8

• Rate? 160 bpm

• Regularity? regular
• P waves? none
• PR interval? none
• QRS duration? wide (> 0.12 sec)
Interpretation? Ventricular Tachycardia
Ventricular Tachycardia

 Deviation from NSR

 Impulse is originating in the ventricles (no
P waves, wide QRS).
Rhythm #9

• Rate? none
• Regularity? irregularly irreg.
• P waves? none
• PR interval? none
• QRS duration? wide, if recognizable
Interpretation? Ventricular Fibrillation
Ventricular Fibrillation

 Deviation from NSR

 Completely abnormal.
Arrhythmia Formation

Arrhythmias can arise from problems in the:

• Sinus node
• Atrial cells
• AV junction
• Ventricular cells
SA Node Problems

The SA Node can:

 fire too slow
 fire too fast Sinus Bradycardia
Sinus Tachycardia

Sinus Tachycardia may be an appropriate

response to stress.
Rhythm #1

• Rate? 30 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.12 s
• QRS duration? 0.10 s
Interpretation? Sinus Bradycardia
Rhythm #2

• Rate? 130 bpm

• Regularity? regular
• P waves? normal
• PR interval? 0.16 s
• QRS duration? 0.08 s
Interpretation? Sinus Tachycardia
Rhythm #3

• Rate? 70 bpm
• Regularity? occasionally irreg.
• P waves? 2/7 different contour
• PR interval? 0.14 s (except 2/7)
• QRS duration? 0.08 s
Interpretation? NSR with Premature Atrial
Contractions
Premature Atrial
Contractions

 Deviation from NSR

 These ectopic beats originate in the
atria (but not in the SA node), therefore
the contour of the P wave, the PR
interval, and the timing are different
than a normally generated pulse from
the SA node.
Rhythm #4

• Rate? 60 bpm
• Regularity? occasionally irreg.
• P waves? none for 7th QRS
• PR interval? 0.14 s
• QRS duration? 0.08 s (7th wide)
Interpretation? Sinus Rhythm with 1 PVC
Ventricular Conduction

Normal Abnormal
Signal moves rapidly Signal moves slowly
through the ventricles through the ventricles
Rhythm #10

• Rate? 60 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.36 s
• QRS duration? 0.08 s
Interpretation? 1st Degree AV Block
Rhythm #5

• Rate? 100 bpm

• Regularity? irregularly irregular
• P waves? none
• PR interval? none
• QRS duration? 0.06 s
Interpretation? Atrial Fibrillation
Atrial Fibrillation

 Deviation from NSR

 No organized atrial depolarization, so no
normal P waves (impulses are not
originating from the sinus node).
 Atrial activity is chaotic (resulting in an
irregularly irregular rate).
 Common, affects 2-4%, up to 5-10% if > 80
years old
Rhythm #6

• Rate? 70 bpm
• Regularity? regular
• P waves? flutter waves
• PR interval? none
• QRS duration? 0.06 s
Interpretation? Atrial Flutter
Ventricular Arrhythmias

 Ventricular Tachycardia

 Ventricular Fibrillation
Rhythm #8

• Rate? 160 bpm

• Regularity? regular
• P waves? none
• PR interval? none
• QRS duration? wide (> 0.12 sec)
Interpretation? Ventricular Tachycardia
Ventricular Tachycardia

 Deviation from NSR

 Impulse is originating in the ventricles (no
P waves, wide QRS).
Rhythm #9

• Rate? none
• Regularity? irregularly irreg.
• P waves? none
• PR interval? none
• QRS duration? wide, if recognizable
Interpretation? Ventricular Fibrillation
Ventricular Fibrillation

 Deviation from NSR

 Completely abnormal.
Diagnosing a MI

To diagnose a myocardial infarction you need to

go beyond looking at a rhythm strip and obtain
a 12-Lead ECG.

12-Lead
ECG

Rhythm
Strip
Views of the Heart

Some leads get a Lateral portion

good view of the: of the heart

Anterior portion
of the heart

Inferior portion
of the heart
ST Elevation

One way to
diagnose an
acute MI is to
look for
elevation of the
ST segment.
ST Elevation (cont)

Elevation of the ST
segment (greater
than 1 small box) in
2 leads is consistent
with a myocardial
infarction.
Anterior View of the Heart

The anterior portion of the heart is best viewed

using leads V1- V4.
Anterior Myocardial
Infarction
If you see changes in leads V1 - V4 that
are consistent with a myocardial
infarction, you can conclude that it is
an anterior wall myocardial infarction.
Putting it all Together

Do you think this person is having a

myocardial infarction. If so, where?
Interpretation

Yes, this person is having an acute anterior

wall myocardial infarction.
Other MI Locations

Now that you know where to look for an

anterior wall myocardial infarction let’s look at
how you would determine if the MI involves
the lateral wall or the inferior wall of the heart.
Anterior MI

Remember the anterior portion of the heart is best

viewed using leads V1- V4.
Limb Leads Augmented Leads Precordial Leads
Lateral MI

So what leads do you think

the lateral portion of the
heart is best viewed? Leads I, aVL, and V5- V6

Limb Leads Augmented Leads Precordial Leads

Inferior MI

Now how about the

inferior portion of the
heart? Leads II, III and aVF

Limb Leads Augmented Leads Precordial Leads

Putting it all Together

Now, where do you think this person is

having a myocardial infarction?
Inferior Wall MI

This is an inferior MI. Note the ST elevation in

leads II, III and aVF.
Putting it all Together

How about now?

Anterolateral MI

This person’s MI involves both the anterior wall

(V2-V4) and the lateral wall (V5-V6, I, and aVL)!
Right Bundle Branch Blocks

What QRS morphology is characteristic?

For RBBB the wide QRS complex assumes a
unique, virtually diagnostic shape in those
leads overlying the right ventricle (V1 and V2).

V1

“Rabbit Ears”
RBBB
Left Bundle Branch Blocks

What QRS morphology is characteristic?

For LBBB the wide QRS complex assumes a
characteristic change in shape in those leads
opposite the left ventricle (right ventricular
leads - V1 and V2).

Broad,
Normal deep S
waves